Delivering dual benefits

Sandra Andrade lay in her hospital bed, overcome with anxiety about her newborn son.

All through her pregnancy, she had worried. The placenta was blocking her birth canal and growing into other organs. She knew she needed a Cesarean: If she went into labor, she might bleed to death.

Now her boy was in intensive care at Women's and Children's Hospital at Los Angeles County USC Medical Center. With his future -- and her own recovery -- on her mind, Andrade, 36, was relieved to be spared at least one worry: Who would pay for their care.

She'd been without private insurance since the premiums became too costly. But a friend assured her that, even as an illegal immigrant from Colombia, she would qualify for Medi-Cal, the state and federal health insurance program for the poor.

Andrade, a clothing exporter, is one of more than 100,000 undocumented women each year who bear children in California with expenses paid by Medi-Cal, according to state reports. They now account for about one in five births.

Regardless of their parents' status, the children are American citizens by law.

Many illegal immigrants who might otherwise shy away from government services view care associated with childbirth as something they can safely seek, a protected right.

"I wasn't afraid at all," said Andrade, who came to the United States with her daughters on a tourist visa and stayed here with her boyfriend after it expired. "I'd always heard that pregnant women are treated well here."

California long has been one of the more generous states in offering such benefits, covering everything from pregnancy tests to postpartum checkups for impoverished illegal immigrants.

'Birthright' citizenship

Such births and associated expenses account for more than $400 million of the nearly $1 billion that the program spends each year on healthcare for illegal immigrants in California, documents and reports show. Only about a dozen other states extend similar benefits to illegal immigrants, according to health and immigrant rights groups.

Although it has not so far figured prominently in the national discussion of immigration reform, a debate is simmering about the costs -- and the rights -- of illegal immigrants' American-born children.

Some advocates for immigration control want to abolish automatic or "birthright" citizenship for babies born to undocumented women in the United States. They consider it just the first in an unacceptably long line of public benefits flowing to children who were born here only because their mothers broke the law.

"I think most Americans think that -- while they certainly don't want to do anything to harm children -- you cannot have a policy that says anybody in the world come here and have a baby and we have a new American," said Ira Mehlman, a spokesman for the Federation of American Immigration Reform, an immigration control group based in Washington, D.C.

One of the most controversial aspects of coverage has been prenatal care. Labor and delivery long have been considered emergencies, entitled to some federal reimbursement. But federal officials have balked at covering prenatal care since at least the 1980s. (Generally, the state and federal governments share the cost of Medicaid programs -- called Medi-Cal in California.)

In 1989, California passed a law guaranteeing prenatal care to all impoverished women, with the state footing the bill. Last year, it began to tap federal funds dedicated to healthcare for working families, under the theory that the fetus would ultimately be an American child. Some other states have done the same.

Those who favor such coverage say it's cheaper to pay for prenatal care than risk complications that could saddle the U.S. government with staggering medical bills.

An often-cited 1985 study by the Institute of Medicine found that every dollar spent on prenatal care saved more than $3 in medical costs by reducing the number of underweight babies and other problems.

'A serious risk'

"Without prenatal care, there's a serious risk that a child will be born with severe disabilities," said Lucy Quacinella, a lobbyist for the Los Angeles-based social service nonprofit group Maternal and Child Health Access. "The cost of caring for that child over a lifetime is astronomical when you compare the cost of having provided the prenatal care for the mother."

Investing in pregnant illegal immigrants and their children is no small undertaking.

Births and prenatal care are the biggest single outlay by Medi-Cal for illegal immigrants' healthcare, with the rest going for various other emergency treatments, limited breast and cervical cancer treatment, abortions and some nursing home care, according to the state.

In Los Angeles County's public and private hospitals, undocumented women accounted for 41,240 Medi-Cal births in 2004, roughly half the deliveries covered by the public program.

In the four county-run hospitals alone, undocumented women and their newborns will receive more than $20 million in delivery, recovery, nursery and neonatal ICU services this year, according to a county estimate.

State figures indicate that regular births and prenatal and postnatal care cost an average of $3,224 and Caesarean deliveries $5,153.

But complications can cost tens or even hundreds of thousands of dollars.

Andrade's son, for instance, spent 10 days in an incubator. County officials said it costs about $3,000 a day to care for an infant in a neonatal intensive care unit.

Whatever the costs, some immigrants and their advocates insist that they can't be considered in a vacuum.

Illegal immigrants contribute to the economy in the form of cheap labor, as well as sales and payroll taxes, including payments to Social Security, which many will never collect.

'I didn't pay anything'

"My husband pays taxes. They take a bunch out of his paycheck," Ludys Ortiz, 36, said as she nursed her newborn son Christian at Women and Children's Hospital, down the hall from Andrade.

Her husband works for $12 an hour washing cars at a body shop.

Ortiz, who entered the U.S. illegally in 2004 from Honduras, worked as a caretaker for children and the elderly, then as a house cleaner.

The pregnancy was unexpected.

"I am embarrassed because I'm not from here, I didn't pay anything and they delivered my baby without my having to pay anything," she said.

"But I'm more grateful than ashamed, because there's no sin in asking for help, only in stealing.

"We all have some rights in life. No matter what, we're human beings," she added. "The only thing that divides us is a few pieces of paper."

Ortiz, who was caught by immigration authorities in Texas shortly after her arrival, is not planning to stay in the U.S., however. She said she desperately misses her daughter in Central America and will tell the judge she wants to go home, taking her son with her. Her family's mission in the U.S. was accomplished: earning enough money to build a tile-roofed house in the Choluteca province of Honduras.

In at least one sense, births to illegal immigrants contribute to the U.S. economy, or at least to hospitals that serve a large number of poor patients.

The federal government pays them a subsidy: For each Medi-Cal birth, hospitals can count two patients -- mother and child -- substantially boosting compensation for relatively inexpensive procedures.

Medi-Cal "pays even more than insurance" for obstetrics, said Gary Wells, chief financial officer of the Los Angeles County Department of Health Services.

Courting patients

As a result, some private hospitals have expanded their delivery wings in the last decade or so, advertising their services on billboards and fliers.

"At one time, there was a billboard next to County-USC encouraging expectant mothers to come to White Memorial," a nearby private medical center, Wells said.

Los Angeles County public hospitals -- once so overwhelmed with deliveries that some women underwent labor in hallways -- now are quiet. Most recovery beds at Women and Children's Hospital were empty during two visits this fall.

As the county hospitals slowed down, private hospitals -- and the clinics that feed to them -- became swamped. South Central Family Health Center sends patients mostly to California Hospital Medical Center in downtown Los Angeles, which delivers more than 4,000 Medi-Cal babies a year.

Pregnant women enter the nonprofit community clinic by the dozens on Monday afternoons, when three family doctors and a nurse provide prenatal care.

On one recent Monday, Dr. Kathryn White saw 11 patients in the afternoon, at least seven of them illegal immigrants.

One after another they came, needing care for gestational diabetes, anemia, a heart murmur and urinary tract infections. One returned to check her biopsy report. By 4 p.m., White was on her eighth patient and she'd stopped worrying about time.

"I'll give her a full physical," she said, almost to herself, after a teen reported some bleeding. "What am I going to do, give her an appointment for another slot I don't have?"

In some ways, this clinic's full load is a sign of progress in public health. In Los Angeles, 90% of women receive prenatal care in their first trimester, up from 81% in 1996. For Latinas, who make up the vast majority of undocumented women, the figure is 89%.

Undocumented women who rely on Medi-Cal during pregnancy often express gratitude. Some say they feel a bit guilty, but shame seldom enters the conversation, even when the recipients are from a middle-class background.

"What I think is that we're all immigrants in this country.... Those who were born here are merely children of immigrants, which doesn't give them the right to say that the rest of us don't have the rights," said Sandra Escobar, a Salvadoran who came to the U.S. illegally with her accountant husband to escape the collapsing economy and who unexpectedly became pregnant.

"My son will always be the child of an immigrant," she said, gazing at the moon-faced newborn she was nursing at Women and Children's Hospital.

Limited coverage

For many undocumented women, pregnancy and child birth will be the only time in their lives they'll qualify for Medi-Cal or any other state subsidized medical care.

Petra Escobar, a 35-year-old Mexican immigrant who has been living in the United States illegally for 20 years, developed high blood pressure in May while pregnant with her third child. Twice, it shot so high she had to be hospitalized. After the second episode, worried doctors performed an emergency C-section to deliver her seven-month fetus. She said Medi-Cal covered both hospitalizations.

In September, three months after the birth of her son, she had another episode on a busy city street. An ambulance took her to California Hospital Medical Center.

The unemployed former garment factory worker, now ineligible for Medi-Cal, said she received a prescription for a blood pressure medication that costs $100 a month and a bill for $45,000.

It may have to be written off by the private hospital as charity care.

"I don't have that kind of money," she said, arching a brow and showing an empty hand.